Visions Journal

Tania Lecomte, PhD, RPsych, and Alicia Spidel, MA, PhD Candidate

Reprinted from the Mindfulness issue of Visions Journal, 2016, 12 (2), p. 10

Mindfulness and cognitive-behavioural therapies such as acceptance and commitment therapy (ACT),¹ compassionate mind training,² and mindfulness-based cognitive therapy (MBCT)³ all share a common goal—that of helping individuals live with negative experiences or emotions by staying with those experiences or emotions instead of trying to avoid them. To be mindful refers to being in the present moment while being aware of what is going on in our minds, bodies and emotions. Mindfulness can be practised in many ways, such as being contemplative while taking a walk, breathing calmly during negative emotions such as sadness or anger, imagining a happy place when one is stressed out (a self-compassion technique) or meditating, to name a few.

Are mindfulness-based treatments dangerous?

For a long time, practising meditation—one of the strategies used in mindfulness-based interventions—was considered dangerous for people with mental illness, especially individuals with psychosis (that is, people who have experienced temporary loss of contact with reality, often involving odd beliefs and hearing voices). Clinicians believed that meditation could trigger a psychotic episode by creating a mental state in which the person was no longer connected to reality and would let his or her mind take over. This belief was not entirely unfounded. In fact, unguided meditation practices can be harmful for people with a diagnosis of a psychotic disorder and have indeed been documented as worsening the psychotic symptoms of some individuals.⁴ Yet not all mindfulness practice includes meditation, and mindfulness interventions are being recommended more commonly for people with psychosis, as can be seen by the number of publications on the subject in recent years.

What does this mean?

Although few rigorous studies to date have investigated the impact of mindfulness interventions for psychosis,⁵ the results seem to suggest that this type of treatment might be useful when it is carefully adapted to the needs of people with psychosis. Mindfulness may work by helping the individual to better cope with difficult emotions and symptoms, such as sadness (depression) and fear (anxiety), and with the high levels of stress that the individual with psychosis often experiences daily.

How mindfulness-based interventions work

Unlike cognitive-behavioural therapy for psychosis, which has shown to help diminish psychotic symptoms,⁶ mindfulness interventions appear to help people with psychosis to get out of their head and be more present in the moment. Mindfulness treatments do not aim to decrease the occurrence or severity of the symptoms of psychosis, but by helping to reduce the distress people experience, many of these treatments help indirectly to alleviate psychotic symptoms as well. It might seem less of a priority to offer a treatment that does not have a direct or strong effect on an individual’s psychotic symptoms (such as hallucinations, or hearing voices, and delusions, odd beliefs). Yet individuals with psychosis often experience difficulty regulating their emotions,⁷ which can leave them feeling overwhelmed and overstressed and vulnerable to severe symptoms of depression and anxiety, as well as drug and alcohol problems. The relative success of mindfulness-based treatments suggests that these strategies may help to improve the overall mental well-being of individuals with psychosis.

Most mindfulness treatments for psychosis aim to help the individual incorporate the following into his or her daily routine:

• Acceptance (“Okay, so I am feeling this way, but it will pass.”)

• Taking a step back (“What is going on? Why am I feeling this way?”)

• Compassion (“I have to stop being so hard on myself; I can be nicer to myself.”)

• Mindfulness (“I am aware in the here and now.”)

Important adaptations to mindfulness practice

Over the past several years, mindfulness-based treatments have been adapted for people with psychosis in order to improve the impact of the techniques for this group of individuals and to avoid harm. For example, mindfulness meditation for people with psychosis needs to be focused on real-life awareness and physical cues (for example, a focus on breathing, or a focus on muscle relaxation). Meditation practices that focus on more esoteric philosophies (cosmic energy, the third eye, the body’s chakras and so on) may encourage a negative response in individuals with psychosis. Mindfulness meditation practices should also be brief and clinician-guided. Almost all reported cases of meditation-induced psychosis took place during meditation retreats where people meditated for several hours each day.⁴

It is also important to remember that mindfulness practice need not involve meditation. For instance, in the course of our research, a young man with psychosis who reported practising mindfulness primarily while he walked (by focusing on his senses and his environment instead of his thoughts) also reported being able to have his first conversation with his parents in years. He explained that since he had begun practising mindfulness he was not as obsessed with his own thoughts and was more available and interested in other people.

Another thing to keep in mind when adapting mindfulness strategies is that people with psychotic disorders do not always understand the idiomatic language common to most contemporary mindfulness teaching. Some mindfulness-based treatments, for instance, use various metaphors (for example, “You are the bus driver of your life and the passengers are your thoughts and emotions”). This type of language is not always helpful to individuals with psychosis, who frequently have a concrete way of thinking and may not grasp the intended meaning.

In the context of our own studies investigating the impact of a specific mindfulness therapy for people with early psychosis who have also experienced trauma or who also suffer from social anxiety, we have had participants understand mindful eating activities (where individuals learn to focus on their senses instead of their thoughts while eating) as a lifestyle lesson (“It is important to eat slowly”). In some cases, simple adaptations can help ensure that the individual’s mindfulness practice is personally meaningful. Participants in one of our current studies found it easier to practise when they had an audio recording of the therapist guiding them in using mindfulness strategies in practice sessions at home. We have also found that, for people with psychosis without severe social anxiety, learning mindfulness strategies in a group format is greatly appreciated and offers clear benefits—in terms of participants being more active, less depressed and less anxious.⁸ Individuals with psychosis and a history of trauma have also been found to benefit from ACT (a specific therapy involving mindfulness) in a group format.⁹

More studies are needed to determine the clinical impact, especially the long-term effects, of mindfulness treatments for individuals with psychosis. We also need to investigate who is most likely to benefit from these treatments. This research is increasingly important as mindfulness treatments are becoming more popular, in part because they are non-invasive and based on well-accepted values (non-judgement and compassion, for example), and in part because the treatments are brief. In fact, most mindfulness treatments for psychosis are fewer than ten sessions. Mindfulness treatments may also prove more effective when offered along with other treatments, such as cognitive-behavioural therapy, and when offered alongside a recovery treatment plan that focuses on the individual’s needs and goals in terms of physical health, mental health and vocational and social recovery. Although mindfulness treatments are not yet widely accessible, their increasing popularity will likely lead to their being offered by more clinicians in a wider variety of settings in the near future.